Healthcare Provider Details

I. General information

NPI: 1265637045
Provider Name (Legal Business Name): KELLIE MARISSA SPRANGEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 G ST
SPRINGFIELD OR
97477-4112
US

IV. Provider business mailing address

PO BOX 708850
SANDY UT
84070-8850
US

V. Phone/Fax

Practice location:
  • Phone: 541-744-8555
  • Fax:
Mailing address:
  • Phone: 866-869-2395
  • Fax: 801-352-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD20607
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: